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Field Based Treatment of Field Based Treatment of Chlamydia and Gonorrhea Chlamydia and Gonorrhea Nilmarie Guzmán,MD Nilmarie Guzmán,MD & Michael & Michael Sands,MD Sands,MD University of Florida/Jacksonville and University of Florida/Jacksonville and the Duval County Health Department the Duval County Health Department

Field Based Treatment of Chlamydia and Gonorrhea Nilmarie Guzmán,MD & Michael Sands,MD University of Florida/Jacksonville and the Duval County Health Department

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Page 1: Field Based Treatment of Chlamydia and Gonorrhea Nilmarie Guzmán,MD & Michael Sands,MD University of Florida/Jacksonville and the Duval County Health Department

Field Based Treatment of Field Based Treatment of Chlamydia and GonorrheaChlamydia and Gonorrhea

Nilmarie Guzmán,MDNilmarie Guzmán,MD & Michael Sands,MD & Michael Sands,MD

University of Florida/Jacksonville and the Duval University of Florida/Jacksonville and the Duval County Health DepartmentCounty Health Department

Page 2: Field Based Treatment of Chlamydia and Gonorrhea Nilmarie Guzmán,MD & Michael Sands,MD University of Florida/Jacksonville and the Duval County Health Department

Gonorrhea and ChlamydiaGonorrhea and ChlamydiaBackgroundBackground • Chlamydia and gonorrhea represent significant health Chlamydia and gonorrhea represent significant health

problems in young adultsproblems in young adults• Both are associated with genital and reproductive Both are associated with genital and reproductive

morbidity in womenmorbidity in women– PIDPID– InfertilityInfertility– Ectopic pregnancyEctopic pregnancy

• Urethritis is associated with increased risk of Urethritis is associated with increased risk of transmission and acquisition of HIV infectiontransmission and acquisition of HIV infection

• Racial disparities in prevalence of GC and CT in young Racial disparities in prevalence of GC and CT in young AA men and womenAA men and women

Page 3: Field Based Treatment of Chlamydia and Gonorrhea Nilmarie Guzmán,MD & Michael Sands,MD University of Florida/Jacksonville and the Duval County Health Department

Duval County, FloridaDuval County, Florida

• 55thth largest county in Florida largest county in Florida• Population of 850,000Population of 850,000• Relatively young demographicsRelatively young demographics

– Mean age 33.8 yearsMean age 33.8 years– 30% of the population is under 35 y/o30% of the population is under 35 y/o

• Highest rates of Chlamydia and Highest rates of Chlamydia and Gonorrhea in 15 – 19 year olds in FloridaGonorrhea in 15 – 19 year olds in Florida

• Significant racial disparity Significant racial disparity

Page 4: Field Based Treatment of Chlamydia and Gonorrhea Nilmarie Guzmán,MD & Michael Sands,MD University of Florida/Jacksonville and the Duval County Health Department

Chlamydia cases by age and raceChlamydia cases by age and raceDuval County 2004Duval County 2004

0

20

40

60

80

100

120

140

160

180

0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-54 55-64 65++ Unk

Unk - u

Unk - f

Unk - m

other - u

other - f

other - m

Hispanic - u

Hispanic - f

Hispanic - m

White - u

White - f

White - m

Black - u

Black - f

Black - m

Asian/Pac.Islander - u

Asian/Pac.Islander - f

Asian/Pac.Islander - m

American Indian - u

American Indian - f

American Indian - m

MONTH (All) Reporting Source STD disease Chlamydia year 2004 STATE (All) county DUVAL

Age

race/ethnic

sex

Page 5: Field Based Treatment of Chlamydia and Gonorrhea Nilmarie Guzmán,MD & Michael Sands,MD University of Florida/Jacksonville and the Duval County Health Department

Gonorrhea cases by age and raceGonorrhea cases by age and raceDuval County 2004Duval County 2004

0

20

40

60

80

100

120

140

160

180

0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-54 55-64 65++ Unk

Unk - u

Unk - f

Unk - m

other - u

other - f

other - m

Hispanic - u

Hispanic - f

Hispanic - m

White - u

White - f

White - m

Black - u

Black - f

Black - m

Asian/Pac.Islander - u

Asian/Pac.Islander - f

Asian/Pac.Islander - m

American Indian - u

American Indian - f

American Indian - m

MONTH (All) Reporting Source STD disease Gonorrhea year 2004 STATE (All) county DUVAL

Age

race/ethnic

sex

Page 6: Field Based Treatment of Chlamydia and Gonorrhea Nilmarie Guzmán,MD & Michael Sands,MD University of Florida/Jacksonville and the Duval County Health Department

0

50

100

150

200

250

15 - 24 25 - 34 35 - 44

Age group

Ectopic Pregnancy Rates - 3 year aggregate 2001-2003

WW/10K population

BW/10K population

WW/10K births

BW/10K births

Cases

Page 7: Field Based Treatment of Chlamydia and Gonorrhea Nilmarie Guzmán,MD & Michael Sands,MD University of Florida/Jacksonville and the Duval County Health Department

Approaches to Improve GC & CT Approaches to Improve GC & CT Therapy RatesTherapy Rates

• Standard partner referralStandard partner referral• Expedited partner therapy (EPT)/Patient Expedited partner therapy (EPT)/Patient

delivered partner therapy (PDPT)delivered partner therapy (PDPT)– Probably a useful adjunct for infected heterosexual men Probably a useful adjunct for infected heterosexual men

and womenand women– No data for MSM or adolescent populationsNo data for MSM or adolescent populations– Depends upon the “honesty” of the partner to deliver Depends upon the “honesty” of the partner to deliver

medicationmedication– Legal limitations to medication delivery in many statesLegal limitations to medication delivery in many states– Missed opportunity for testing other STDs, HIV and for Missed opportunity for testing other STDs, HIV and for

prevention counselingprevention counseling

• Field based therapyField based therapy– Very limited published experienceVery limited published experience

Page 8: Field Based Treatment of Chlamydia and Gonorrhea Nilmarie Guzmán,MD & Michael Sands,MD University of Florida/Jacksonville and the Duval County Health Department

Field Based Therapy for GC & Field Based Therapy for GC & Chlamydia in Duval CountyChlamydia in Duval County

• Field based therapy, contact investigation, Field based therapy, contact investigation, prevention counseling and testing prevention counseling and testing

• Conducted by trained STD field workersConducted by trained STD field workers

• Utilizing an established written protocolUtilizing an established written protocol

• Physician available by phonePhysician available by phone

• Targeting all 15-24 year olds diagnosed Targeting all 15-24 year olds diagnosed with GC or CT infectionswith GC or CT infections

Page 9: Field Based Treatment of Chlamydia and Gonorrhea Nilmarie Guzmán,MD & Michael Sands,MD University of Florida/Jacksonville and the Duval County Health Department

Field Based Therapy for GC & Field Based Therapy for GC & Chlamydia in Duval CountyChlamydia in Duval County

• Assure appropriate treatment of infectionAssure appropriate treatment of infection

• Contact interviewContact interview

• Prevention counselingPrevention counseling

• Condom distributionCondom distribution

• Syphilis and HIV serotesting with consentSyphilis and HIV serotesting with consent

Page 10: Field Based Treatment of Chlamydia and Gonorrhea Nilmarie Guzmán,MD & Michael Sands,MD University of Florida/Jacksonville and the Duval County Health Department

0

5

10

15

20

25

30

AA W 15-24 AA M 15-24 AA W > 25 AA M > 25

1

2

3

4

5

6

>6

Number of Sexual Partners in the Last 12 Months

Cases

Page 11: Field Based Treatment of Chlamydia and Gonorrhea Nilmarie Guzmán,MD & Michael Sands,MD University of Florida/Jacksonville and the Duval County Health Department

Chlamydia outcomes in the 15 – 24 y/o Chlamydia outcomes in the 15 – 24 y/o High Risk Target PopulationHigh Risk Target Population

0

100

200

300

400

500

600

700

800

900

1000

1 - 6 04 6 - 12 04 1 - 6 05

Eligible

Interviewed & Rx

Partners

Cases

Page 12: Field Based Treatment of Chlamydia and Gonorrhea Nilmarie Guzmán,MD & Michael Sands,MD University of Florida/Jacksonville and the Duval County Health Department

Partner Management under Field Partner Management under Field Based TherapyBased Therapy • Attempt was made to locate all partnersAttempt was made to locate all partners• Partner received field based “epidemiologic Partner received field based “epidemiologic

treatment” using a standard USPHS regimen if treatment” using a standard USPHS regimen if not already treatednot already treated

• Partners were offered HIV and syphilis serotestingPartners were offered HIV and syphilis serotesting• Prevention counseling and condoms distributionPrevention counseling and condoms distribution• All contacts had field urines collected for GC & CT All contacts had field urines collected for GC & CT

probe testingprobe testing• Men had a LE test done in the field and those Men had a LE test done in the field and those

found positive 2+ or greater had contact found positive 2+ or greater had contact interviews done during the initial visitinterviews done during the initial visit

Page 13: Field Based Treatment of Chlamydia and Gonorrhea Nilmarie Guzmán,MD & Michael Sands,MD University of Florida/Jacksonville and the Duval County Health Department

0

100

200

300

400

500

600

700

800

Cases

1 - 6 03 7 - 12 04 1 - 6 05

6 Month Time Period

Chlamydia Contact Outcomes 15 - 24 Y/O

Partners Not Located

Partners Previously Tx

Partners Infected & Tx

Partners Located & Epi Tx

Page 14: Field Based Treatment of Chlamydia and Gonorrhea Nilmarie Guzmán,MD & Michael Sands,MD University of Florida/Jacksonville and the Duval County Health Department

HIV Serotesting in ContactsHIV Serotesting in Contacts

• Field base intervention enables professional Field base intervention enables professional prevention counseling and serotesting for HIV in prevention counseling and serotesting for HIV in high risk populationshigh risk populations

• Acceptance of HIV testing evaluated in 200 Acceptance of HIV testing evaluated in 200 contact investigations performed during Jan – contact investigations performed during Jan – June 05June 05– 75% of AA women accepted testing75% of AA women accepted testing– 57% of AA men accepted testing57% of AA men accepted testing– Three new cases of HIV were identified and linked to Three new cases of HIV were identified and linked to

carecare

Page 15: Field Based Treatment of Chlamydia and Gonorrhea Nilmarie Guzmán,MD & Michael Sands,MD University of Florida/Jacksonville and the Duval County Health Department

SummarySummary

• Field based intervention is an effective strategy for STD Field based intervention is an effective strategy for STD programsprograms

• It can be accomplished successfully by trained field staff It can be accomplished successfully by trained field staff working under protocolworking under protocol

• This is particularly useful for high risk target groups ie. This is particularly useful for high risk target groups ie. adolescents and young adultsadolescents and young adults

• More patients can be brought into therapy than utilizing More patients can be brought into therapy than utilizing solely clinic based programssolely clinic based programs

• Prevention activities are incorporated into the programPrevention activities are incorporated into the program• Further evaluation of FBT in other populations ie MSM Further evaluation of FBT in other populations ie MSM

and adult heterosexual men and women should be doneand adult heterosexual men and women should be done